Online Membership Application

Please select your membership type

Active (One Year Membership Fee: $195)
Affiliate (One Year Membership Fee: $95)
Associate (One Year Membership Fee: $95)

IFSO Membership

IFSO Obesity Surgery (One Year Membership Fee: $100)
IFSO Obesity Surgery and SOARD (One Year Membership Fee: $192)
IFSO Membership (non-surgeons) (One Year Membership Fee: $20)

None

Personal Information

Title:
First name:
Last name:

Professional Information

Title
Hospital Affiliation
Practice Type

Medical Education

University
City
Province / State
Country
Degrees
Year of Graduation
I am a Member of (Provincial/State Licensing Board)

Active Members

Check the procedures/treatments you perform:

	Laparoscopic Gastric Banding
	Laparoscopic BPD with Duodenal Switch
	Laparoscopic Sleeve Gastrectomy
	Open BPD with/without Duodenal Switch
	Revisional surgery
	Medical Interventions
	Behavioral Interventions
	Specialized Diets (e.g. VLCD)
Other (specify)

E-mail address

CANADA ANTI-SPAM REQUIREMENTS:

This section MUST be completed in order for the application to be processed. CABPS communicates electronically with its membership; in accordance with the Canada Anti-Spam Law, you must indicate whether you wish to receive electronic correspondence from us:

E-mail address
Electronic Correspondence	I AGREE to receive electronic correspondence I DO NOT wish to receive electronic correspondence

Principal Office/Address

Company:
Salutation:
Designation:
Position:
Address Line 1
Address Line 2
Address Line 3
City
Province	Please select a province... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code
Country

Home Address

Home Address Line 1
Home Address Line 2
Home Address Line 3
Home City
Home Province	Please select a province... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Home Postal Code
Home Country

Contact Information

Preferred Correspondence	Principal Office Home
Work Phone Number
Home Phone Number
Mobile Phone Number
Other Phone
Fax Number
Website

Member Directory

Payment Information

Total:	$0.00
Name on Card: *
Card Number: *
CVC: *
Expiration (MM/YYYY): *	/

 

Submit